Quick facts

Service type: Health & Wellness
Eligibility: Adults 18+ with complex health conditions residing in mid-East/East Toronto. For additional considerations, please see below.
Delivery: In person, virtual, phone
Fee: Free
Partners: East Toronto Health Partners, COTA, St. Michael's Homes, Michael Garron Hospital

Program description

WoodGreen’s clinical social workers strive to fill gaps in care for clients living with complex health and psychosocial issues. Our Comprehensive Care and Integration Specialists connect clients to essential services and supports; coordinate follow-up care; and provide case management, counselling and advocacy on housing, legal, financial and immigration issues. We work with clients to develop individual Coordinated Care Plans and support their care providers to work as a team. Our goal is to bridge the gap between acute and medical care providers and the community sector.

Additional eligibility requirements



  • With significant gaps in care
  • Who may struggle to follow up on care recommendations
  • Who have a history of multiple Emergency Department (ED) visits, are Alternate Level of Care (ALC) or at risk for ongoing visits and in-patient stays
  • Who experience challenges related to the social determinants of health (e.g., housing, income)
  • Who would benefit from integrating the work of multiple health providers


Please consider referring clients with complex health needs from the following groups:


  • Individuals experiencing mental health and/or addiction issues
  • Psychogeriatric populations (55+ with mental health and/or addiction issues)
  • Frail elderly

How you can help

Donations are graciously accepted through the WoodGreen Foundation.

Ready to participate?



Referrals required. Health care and support professionals can access the e-referral form here.


To learn more, please contact:

Contact information



Hospitals and other health care settings, community settings (including clients’ homes), and WoodGreen sites


Monday – Friday: 9 a.m. – 5 p.m., with accommodations to meet client needs

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